Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 852550 (X3) Date Survey Completed 10/29/2019
Name of Provider or Supplier Dublin Kidney Institute Street Address, City, State 207 Industrial Blvd Ste 2, Dublin, GA
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
V0000 An onsite survey to investigate complaint #GA00200492, was initiated on October 28, 2019 and concluded on October 29, 2019. The complaint investigation revealed that the facility was not in compliance with 42 CFR Part 494.30, Infection Control and 42 CFR Part 494.180, Governance. The complaint was substantiated. On October 29, 2019, a determination was made that a situation in which the facility's noncompliance with 42 CFR 494.30, Infection Control, resulted in an Immediate Jeopardy with harm to one patient (P#1) and a potential harm to the health and safety of the other two patients (P#2 and P#3), who were under the care of this facility and who dialyzed at a Skilled Nursing Facility. The Facility Administrator was informed of the IJ finding on 10/29/19 at 10:05 a.m. The immediate jeopardy was abated during the survey on 10/29/19 at 4:30 p.m., when the facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy. However, the Conditions remained out of compliance. Also, the following standard level deficiencies were cited.